This information sheet presents an overview of Barrett's esophagus and discusses some of the controversies surrounding the monitoring and treatment of this condition. Each patient will need to decide which options are best for him or her and should gather as much information as possible prior to making any decision.
Barrett's esophagus occurs when the normal cell type that lines the lower part of the esophagus (squamous cells) is replaced by a different cell type (intestinal cells). This process usually results from repetitive damage to the esophageal lining. The most common cause of this is longstanding gastroesophageal reflux disease (GERD), a condition in which the esophagus is exposed to excessive amounts of stomach acid. Interestingly, the intestinal cells of Barrett's esophagus are more resistant to acid than squamous cells, suggesting that they may be an adaptation to the chronic acid exposure. The problem with this adaptation is that the intestinal cells have a small potential to transform into cancer cells.
A wealth of research has identified a number of risk factors associated with Barrett's esophagus:
Barrett's esophagus is most commonly diagnosed in middle-aged and older adults; the average age at diagnosis is 55 years. Children can develop Barrett's esophagus, but rarely before the age of 5 years.
Men are more commonly diagnosed with Barrett's esophagus than women.
Barrett's esophagus is equally common in white and Hispanic populations and is uncommon in black and Asian populations.
Smokers are more commonly diagnosed with Barrett's esophagus than nonsmokers.
Barrett's esophagus itself produces no symptoms. Instead, most patients with this condition seek help because of symptoms of GERD, including heartburn, regurgitation of stomach contents, and, less commonly, difficulty swallowing.
Your doctor may suspect Barrett's esophagus based upon your symptoms and the risk factors described above, but an endoscopy is needed to confirm the presence of an abnormal esophageal lining. During this procedure, a thin lighted tube is passed into the esophagus. By direct visual inspection, normal lining appears pale and glossy, while the Barrett's lining appears pink or red and velvety. Your doctor will usually perform biopsies during the endoscopy (a collection of tissue samples) so that the lining can be examined microscopically. Biopsies are not painful and are very safe.
Endoscopy will detect most (80 percent) but not all cases of Barrett's esophagus. Individual variations in the anatomy of the esophagus and its junction with the stomach can make the diagnosis of Barrett's esophagus tricky.
Patients with Barrett's esophagus are at increased risk for esophageal cancer. Other complications are related to the ongoing acid reflux and may include esophageal ulceration, narrowing, and bleeding.
The chronic inflammation and damage that produce Barrett's esophagus predispose the esophageal lining to malignant (cancerous) changes. Over time, the abnormal lining may show early premalignant changes, which may progress to advanced premalignant changes and finally to frank esophageal cancer. If undetected, this cancer can spread and invade surrounding tissues.
Patients with Barrett's esophagus have a 30-fold increased chance of developing esophageal cancer when compared with the general population--but don't let this statistic alarm you. Progression to cancer is actually uncommon; studies that followed patients with Barrett's esophagus revealed that only 0.5 percent of patients developed esophageal cancer per year. Furthermore, patients with Barrett's esophagus appear to live just as long as people who are free of this condition. Patients often die of some other cause in old age before their Barrett's esophagus progresses to cancer.
The first priority in treating Barrett's esophagus is to stop the ongoing damage of the esophageal lining. This usually means eliminating acid reflux. Your doctor will advise you to avoid certain foods and behaviors that predispose to reflux. Foods that can worsen reflux include:
Acidic juices such as orange or tomato juice may also worsen symptoms. Carbonated beverages can be a problem for some people.
Behaviors that can worsen reflux include eating meals just prior to going to bed, lying down after eating meals, and eating very large meals. Placing bricks or blocks under the posts at the head of your bed (to raise it by about six inches) can take advantage of gravity to keep acid in the stomach while you sleep.
Your doctor will prescribe medications that can suppress the stomach's acid production and decrease reflux into the esophagus. A class of medications called "proton pump inhibitors" are most commonly used to treat reflux in patients with Barrett's. Five different formulations of these drugs are currently available: omeprazole, esomeprazole, lansoprazole, rabeprazole, and pantoprazole, all of which are acceptable options. Their trade names in the United States are Prilosec®, Nexium®, Prevacid®, Aciphex®, and Protonix®, respectively.
Patients who have severe reflux and are good candidates for surgery may benefit from surgical procedures designed to reduce reflux. Surgery is not for everyone, so you should discuss this option with your doctor.
Endoscopic monitoring for premalignant changes is recommended for most patients with Barrett's esophagus. At this time, monitoring entails periodic endoscopy with tissue biopsy. Although new technologies are on the horizon, most are still considered to be experimental.
Experts do not agree about the usefulness of monitoring. The relative benefits of monitoring depend upon each patient's chance of developing esophageal cancer, which may be difficult to determine.
The first step after premalignant changes (dysplasia) are discovered is to confirm their presence with a second opinion. It can sometimes be difficult to correctly identify premalignant changes, especially when there is a background of inflammation (usually caused by the ongoing reflux of acid). Many doctors increase the dose of acid-suppressing medications in these settings.
The second step is to grade the premalignant changes as "low grade" or "high grade," depending upon their severity. If you have low grade dysplasia, your doctor will probably increase your dose of acid suppressing medication and repeat an endoscopy in a few months. If you have high grade dysplasia, the options are more limited. Patients with high grade dysplasia are at much higher risk for developing cancer, and may even already have it. Thus, many doctors recommend surgically removing the esophagus (esophagectomy), although this recommendation has become somewhat controversial. Another option (photodynamic therapy) is also available at some specialized centers.
Photodynamic therapy is based upon the ability of chemical agents, known as photosensitizers, to kill certain types of cells (such as Barrett's cells) in the presence of oxygen after stimulation by light of an appropriate wavelength. Patients are given a photosensitizer and then undergo endoscopy during which a laser light is used to activate the photosensitizer and destroy the Barrett's tissue.
However, there is limited information on the long-term outcome of this approach. Furthermore, photodynamic therapy is expensive, available in only a small number of academic medical centers, and often is complicated by esophageal stricture formation (up to 40 percent), which may require repeated dilation. Another concern is that patients with high-grade dysplasia may have areas of invasive cancer that might not be treated adequately. Thus, photodynamic therapy can be considered for patients with high-grade dysplasia who are poor operative candidates after a thorough discussion of the risks and alternatives.
Despite the uncertainties surrounding the monitoring and treatment of Barrett's esophagus, there is consensus on one matter: The available options should be tailored to each patient. As a critical member of your own health-care team, you should gather as much information as possible, discuss all options with your doctor, and take an active role in your care. The following general guidelines may help you select the best options for you:
A great deal of research is being conducted on Barrett's esophagus. Broadly speaking, the research falls into two categories:
Most of the methods being developed to improve detection of Barrett's and dysplasia involve modifications of standard endoscopy. These include chromoendoscopy (using special dyes to highlight the suspicious areas), magnification endoscopy (using high magnification), endoscopic ultrasound (using ultrasound waves), optical coherence tomography (using specialized optical equipment), and fluorescence detection techniques (using fluorescent dyes). None has yet been proven to work any better than standard endoscopic surveillance.
Several researchers have discovered that it may be possible to restore the normal esophageal lining (squamous cells) in patients with Barrett's esophagus by first destroying the Barrett's lining. Many techniques for destroying the Barrett's lining have been studied. Examples include lasers, cautery, and combination therapy with chemicals and lasers. As of yet, it remains unclear which patients would benefit from these approaches, particularly since they may be associated with side-effects (such as narrowing of the esophagus or creation of a rupture in the esophagus during treatment).
The uncertainty about when to use these approaches is even greater when considering that the majority of patients with Barrett's will not progress to dysplasia, and that the techniques are very expensive. Furthermore, despite the restoration of normal squamous tissue, some Barrett's tissue may remain in the esophagus, which still has the potential to progress to dysplasia and cancer. For these reasons, these techniques should be considered to be experimental.